INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Familylinks Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have counselors complete at least twenty-five clock hours of annual training in one of two applicable records. Staff #4 was hired as a counselor on October 3, 2023 and was still in this position at the time of the inspection. Staff #4 had documented 23.4 hours of training for the January 1, 2025 through December 31, 2025 training year.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The annual training requirements for DDAP will be reviewed with all staff during the 4-10-26 outpatient staff meeting. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26. The overall training plan and implementation will be monitored monthly and quarterly by the Associate Director of Behavioral Health to assure that all trainings and hours of trainings are completed within the required time frames. The Associate Director of Behavioral Health will provide a report to the Director of Behavioral Health quarterly to ensure the plan is followed and completed. The plan will be completed by December 31st of each training year.
Persons Responsible: Associate Director of Behavioral Health, Director of Behavioral Health |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of February 2025 through February 2026, the facility failed to provide documentation of a fire drill being conducted the month of June 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Fire Drills will be conducted monthly by the front office coordinator at the Banksville location. This fire drill will be due by the last day of each month. After the fire drill is conducted, the documentation will be emailed to the supervisor of the Front Office who will upload the fire drill in the monthly health and safety inspection in the Limble Maintenance Application and emailed to the Associate Director of Behavioral Health to ensure that it has been completed. This process will be reviewed by the Associate Director of Behavioral Health by the 5th of the following month for next 6 months to ensure that fire drills are occurring on a monthly basis as required by DDAP regulations.
Persons responsible: Associate Director of Behavioral Health |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include short- and long-term goals for treatment in three of six records. Client #1 was admitted on July 21, 2025 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on July 21, 2025; however, there was no documentation of short-term goals.Client #5 was admitted on September 23, 2025 and was discharged on March 3, 2026. A comprehensive treatment and rehabilitation plan was developed with the client on October 1, 2025; however, there was no documentation of short-term goals.Client #6 was admitted on July 22, 2025 and was discharged on December 11, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on July 22, 2025; however, there was no documentation of short-term goals.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment planning in Welligent EHR will be reviewed with all staff at the 4-10-26 staff meeting. Long term goals (Problems) and short-term goals (Objectives) will be reviewed with staff and a demonstration will occur that will review how to put target dates in the EHR for both of these. After the review at the staff meeting, this will be reviewed individually with each staff during regular supervision during the month of April with all individual reviews occurring by 4-30-26. This process will be implemented beginning 5-1-26.
Person Responsible: Therapist, Associate Director of Behavioral Health
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in five of six records. Client #1 was admitted on July 21, 2025 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on July 21, 2025; there was no documentation of type and frequency of services.Client #2 was admitted on October 9, 2025 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on October 23, 2025; however, there was no documentation of type and frequency of services.Client #3 was admitted on January 6, 2026 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on February 2, 2026; however, there was no documentation of type and frequency of services.Client #5 was admitted on September 23, 2025 and was discharged on March 3, 2026. A comprehensive treatment and rehabilitation plan was developed with the client on October 1, 2025; however, there was no documentation of type and frequency of services.Client #6 was admitted on July 22, 2025 and was discharged on December 11, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on July 22, 2025; however, there was no documentation of type and frequency of services.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the February 5, 2025 annual licensing inspection.
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Plan of Correction
A function was created within the treatment plan in the Welligent electronic health record. Under this function, the therapist will be able to add the type and frequency of treatment to the treatment plan. This process will be reviewed and demonstrated with staff at the 4-10-26 staff meeting. After the review at the staff meeting, this will also be reviewed individually with each staff during regular supervision during the month of April with all individual reviews occurring by 4-30-26. This process will be implemented beginning 5-1-26.
Persons Responsible: Associate Director of Behavioral Health, Director of Behavioral Health
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of applicable client records, the facility failed to document proposed type of support service on individual treatment plans in three of six records.Client #1 was admitted on July 21, 2025 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on July 21, 2025; there was no documentation of proposed type of support service.Client #3 was admitted on January 6, 2026 and was still active at the time of the inspection.A comprehensive treatment and rehabilitation plan was developed with the client on February 2, 2026; however, there was no documentation of proposed type of support service.Client #5 was admitted on September 23, 2025 and was discharged on March 3, 2026. A comprehensive treatment and rehabilitation plan was developed with the client on October 1, 2025; however, there was no documentation of proposed type of support service.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A review of including Support Services that assist the client in completing their goals in the treatment plan will be reviewed at 4-10-26 outpatient team meeting with staff. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26.
Responsible person: Therapist, Associate Director of Behavioral Health
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of five applicable records.Client #1 was admitted on July 21, 2025 and was still active at the time of the inspection.A treatment and rehabilitation plan update was completed on November 20, 2025. The next treatment and rehabilitation plan update was due no later than January 20, 2026; however, this was not completed until January 22, 2026.Client #5 was admitted on September 23, 2025 and was discharged on March 3, 2026. A treatment and rehabilitation plan update was completed on November 26, 2025. The next treatment and rehabilitation plan update was due no later than January 26, 2026; however, this was not completed until February 2, 2026.Client #6 was admitted on July 22, 2025 and was discharged on December 11, 2025. A treatment and rehabilitation plan update was completed on September 19, 2025. The next treatment and rehabilitation plan update was due no later than November 19, 2025; however, this was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The review of the timeline for the preliminary treatment plan and on-going treatment plan updates will be reviewed at the 4-10-26 outpatient staff meeting. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26. Client charts will be reviewed monthly for the next six months or until consistently completed per agency policy and DDAP regulation.
Responsible Person: Associate Director of Behavioral Health
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in three of three applicable records. The facility policy and procedure manual indicate a case consultation to occur prior to client discharge.Client #4 was admitted on December 18, 2025 and was discharged on February 25, 2026. A case consultation was due to occur no later than February 25, 2026; however, this was not completed at the time of the inspection.Client #5 was admitted on September 23, 2025 and was discharged on March 3, 2026. A case consultation was due to occur no later than March 3, 2026; however, this was not completed at the time of the inspection.Client #6 was admitted on July 22, 2025 and was discharged on December 11, 2025. A case consultation was to occur no later than December 11, 2025; however, this was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The review of timelines for case consultations will be reviewed at the 4-10-26 staff meetings. The review of timelines will also be reviewed during individual supervision meetings during the month of April. All individual reviews will occur by 4-30-26. Associate Director of Behavioral Health will review charts monthly to ensure documentation is completed per the agency's timeline.
Responsible Person: Therapist, Associate director of Behavioral Health.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of three records. The policy and procedure manual indicates follow-up contact must be made within seven days of discharge.Client #4 was admitted on December 18, 2025 and was discharged on February 25, 2026. Follow-up contact was due to occur no later than March 4, 2026; however, this was not completed at the time of the inspection.Client #6 was admitted on July 22, 2025 and was discharged on December 11, 2025. Follow-up contact was due to occur no later than December 18, 2025; however, this was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon discharge from the program, a client will be provided a letter that provides follow up information. A copy of the letter and a corresponding coordination care note will be placed in the EHR as verification that follow up was provided to the client. This process will be updated in the Aftercare policy and reviewed at the 4-10-26 outpatient meeting. This will also be reviewed during individual supervisions occurring during the month of April with all individual reviews occurring by 4-30-26. Client discharges will be reviewed monthly for the next six months or until consistently completed per agency policy and DDAP regulation.
Person Responsible: Therapist, Associate Director of Behavioral Health |